With poor respiratory health so prevalent among people who use substances we should seize the opportunity for intervention, as Dr Abida Mohamed explains.
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality in the 21st century and is also associated with a high prevalence of comorbidity. It is a progressive illness, but early intervention improves quality of life (National Institute for Clinical Excellence, 2021).
The main causative factor of COPD is smoking tobacco, and the level of smoking is higher among people who are in substance misuse services than the general population (PHE, 2021). Poor respiratory health was also found to be more prevalent among opioid users (Hulin, 2019).
In the National Drug Treatment Monitoring System (NDTMS) 2020-21 report, 68 per cent of people entering substance misuse treatment in England smoked tobacco. In the 2016 NDTMS report, 45 per cent of people treated for illicit opioid use smoked crack cocaine and 17 per cent smoked cannabis (Hulin, 2019). Despite the high levels of smoking, only 2 per cent of people were recorded as having been offered referrals for smoking cessation interventions (PHE, 2021).
Alcohol, although not a direct cause of COPD, can weaken immune systems, and research has shown that it reduces the production of antioxidants that protect the lung (Kershaw, 2008).
What is COPD?
The research confirms that COPD should be considered a serious health risk as it is the second highest cause of emergency admission in hospitals in the UK. So, what exactly is COPD, and what can we do about it?
COPD comprises emphysema and chronic bronchitis, which are both thought to be directly linked to inhalation of substances, commonly tobacco, but can also include a wider range of inhaled toxins. There are several mechanisms by which opioids may contribute to the cause or consequences of respiratory disease, including suppression of neural respiratory drive, increased airway resistance and as an irritant stimulating histamine release.
Some environments can contribute to the risk of developing COPD, such as air pollution or working with dust and toxins, while people with genetic lung diseases or asthma are also at increased risk.
If left untreated COPD can progress from mild to severe, which can present with weight loss, breathlessness, loss of appetite and heart failure. Most GP surgeries can diagnose COPD with a simple test called spirometry, which looks at how the lungs are functioning and initiate and tailor treatment. The treating clinicians might also request a chest x-ray and blood tests, which will help determine if any co-existing conditions need to be considered.
COPD management firstly aims to reduce the risk factor by promoting smoking cessation, looking at environmental causes and physical health issues. The basic treatment is with inhalers, and regular follow-ups with your GP practice to assess the progression and need for any changes in medication.
COPD and Substance use
Research and meta-analyses of COPD in people who use substances are limited. A meta-analysis undertaken by Hulin et al in 2019 showed a predicted prevalence of 17.9 per cent of COPD in people who inhaled opiates, compared to the estimated general prevalence of between 2-3 per cent.
Conclusions drawn from research highlight the importance of considering the effects of environment and substance use on COPD. Primary health care, housing and substance misuse services should also explore improving living conditions and developing integrated respiratory health surveillance and promotion, while collaborative working between services will improve life expectancy and respiratory health outcomes for people with substance misuse problems (Hulin, 2019).
As clinicians, we need to treat patients holistically and focus on all aspects of comorbidity. A range of skills is essential to promote holistic care, and Delphi recruits staff from a broad multidisciplinary background and encourages this approach to clinical management. A biopsychosocial approach that advocates opportunistic health promotion and intervention forms part of our ethos and drive to improve the quality of life of the people we work with.
COPD is a treatable (not curable) condition, and multi-agency psychosocial and health providers must promote access to resources to bridge the gap between health accessibility and service delivery to improve patients’ quality of life.
The Right Technique
As an NMP, Pamela Lang has a vital role in helping COPD patients to help themselves
In my previous role as a community nurse practitioner, I often provided treatment, care and education for respiratory patients experiencing COPD exacerbation. It was vital to advise when to commence their ‘rescue’ medication or how to use their prescribed inhalers correctly, as it contributed to self-management of a long-term condition. I could transfer and apply the skills and knowledge I had acquired in my previous job to substance misuse clients.
When clients are admitted to the detox unit, they often present with COPD, which is caused by long-term regular smoking and the smoking of heroin/crack cocaine. Education to aid self-management is paramount for our clients as they are only with us for a short period and must be allowed to understand the importance of taking their medication correctly. This, in turn, contributes to compliance and benefits long-term health outcomes.
James was a 38-year-old man who had smoked heroin for the past 12 years. His daily use was between two and three bags, and although a relatively young man, he had a recent diagnosis of COPD after a CT scan showed he had ‘moderate to severe’ upper lobe emphysema. James had been prescribed two inhalers by his GP but very rarely used them, as although he had been shown how, he had forgotten and just used them ad-hoc.
I explained to James that I would assess his technique and teach him when and why he should use his inhalers. He agreed to this. Firstly, I described the differences between the two inhalers. Salbutamol is a short-acting bronchodilator, and the ‘pink’ one (Fostair) is long-acting, and therefore must be taken twice a day, as the effects last around 12 hours.
I explained that the ‘blue’ one, also often referred to as a reliever, was the one that he should have on his person to use when needed, but also pointed out that overuse of the inhaler could result in feeling shaky and anxious, developing a headache and experiencing a fast heartbeat.
James’s technique was very poor, so he was not getting his metered dose when using it and having the impression that it did not work. I introduced an aero chamber and demonstrated how to use it effectively. He struggled at first but eventually began to feel the benefit of the medication and commented that he could feel the difference. Advice was also given on how to clean the aero-chamber and to renew it every six to 12 months.
Pamela Lang is a non-medical prescriber (NMP) at Delphi Medical